DUI INTAKE Please answer as many of the questions as you can. The more information we have the better.Answer the questions that apply. Name * First Name Last Name Date of Birth MM DD YYYY Email * Phone (###) ### #### Address Address 1 Address 2 City State/Province Zip/Postal Code Country Date of Arrest MM DD YYYY Employer Name Employer Phone Number (###) ### #### Employer Address Address 1 Address 2 City State/Province Zip/Postal Code Country Spouse's Name First Name Last Name Spouse Phone Number (###) ### #### Which department arrested you? Location of arrest: provide City, State, and/or Steet/Highway Time of arrest: Your Driver's License Number Any prior arrests? Elaborate: What crimes were you charged with? Where were you going to, and from where? Please explain what happened: (Be as detailed and specific as possible) Did you give a breath or blood test? If so, what was your alcohol level? Did this DUI involve injuries or accident? If so, please explain: Name and phone number of witnesses: Name and phone numbers of all known witnesses Who else was involved? Did you give or sign any statements? If so, what? Any other information you think we should know: Thank you!
